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CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not applicable <br />UNDERGROUND STORAGE TANK <br />MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) <br />This form must be used to document testing and servicing of underground storage tank (UST) monitoring equipment. A copy of this form <br />must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the <br />USTs within 30 days of the date of the monitoring system certification. <br />I. FACILITY INFORMATION <br />CERS ID <br />10182103 <br />Date of Monitoring System Certification <br />05/22/19 <br />Business Name (Same as Facility Name or DBA – Doing Business As.) <br />United Pacific 5446 <br />Building # <br /> <br />Business Site Address <br />1403 County Club Blvd. <br />City <br />Stockton, CA <br />ZIP Code <br />95204 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Company Performing the Certification <br /> <br />Phone # <br />(916) 991 - 1100 <br />Mailing Address <br />5444 Dry Creek Road; Sacramento, CA 95838 <br />Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification.) <br />Richard Thomas <br />Contractor/Tank Tester License # <br />CSLB#803616 SWRB#06-1672 <br />ICC Certification # <br />5254736 <br />ICC Certification Expiration Date <br />11/03/2020 <br />Monitoring System Training and Certifications (List all applicable certifications.) Expiration Date <br />Veeder Root TLS-3XX Cert. #B34022 11/02/2020 <br />Vaporless Manufacturing, Inc. LDT-890 Cert. #2011 08/29/2020 <br />Ronan Engineering Company Cert. #76090602 09/10/2020 <br /> <br />III. RESULTS OF TESTING/SERVICING <br />Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA Monitoring System Set-up Alarm History Report <br />Was any monitoring equipment replaced? <br />(If “Yes,” identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV <br />below.) <br /> <br />Was damage, debris, or liquid found inside any secondary containment systems? <br />(If “Yes,” describe what was found in section IV below.) <br />Is all monitoring equipment operational per manufacturer’s specifications? <br />(If “No,” describe why in section IV below.) <br />IV. COMMENTS <br />If directed to use this section, describe how and when the issues were or will be corrected. <br />1. Power lamp and key pad not 100% functional upon arrival. Replaced key pad with LED lamps. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br />I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of <br />Regulations, title 23, division 3, chapter 16, section 2638 and all information contained herein is true and accurate. Attached to <br />this certification is information (e.g., manufacturers' checklists, monitoring system set-up, alarm history report, etc.) necessary <br />to verify that this information and the site plan showing the layout of UST system is complete and accurate. <br />UST Service Technician Signature <br /> Richard Thomas <br />